Provider Demographics
NPI:1730462706
Name:HENDERSON, DEANDRA RENEE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:DEANDRA
Middle Name:RENEE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 HILLSTONE RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44121-2473
Mailing Address - Country:US
Mailing Address - Phone:216-835-1724
Mailing Address - Fax:
Practice Address - Street 1:1070 HILLSTONE RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44121-2473
Practice Address - Country:US
Practice Address - Phone:216-835-1724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN125915164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse